The Care Quality Commission
  • Care Home
  • Care home

Ashlett Dale Rest Home

Overall: Requires improvement read more about inspection ratings

Stonehills, Fawley, Southampton, Hampshire, SO45 1DU (023) 8089 2075

Provided and run by:
Mrs Collette Willis

Important: The provider of this service changed - see old profile
Important: The provider of this service has requested a review of one or more of the ratings.

All Inspections

During an assessment under our new approach

Date of Assessment: 04 December 2024 to 20 December 2024.

This assessment was carried out in response to concerns about how falls were managed, including risk assessment and incident reporting. There were also concerns relating to staff training and competency and knowledge of mental capacity issues.

The registered manager promoted a learning culture and people could raise concerns. However, this would be better supported through more robust systems and processes of management.

Staff received training in safeguarding. Recent safeguarding referrals had been made appropriately.

Care plans and risk assessments were sometimes generic and did not always contain clear guidance for staff. Follow up actions were not always recorded or monitored effectively.

Systems and procedures for recruiting new staff were not robust. The registered manager told us staff were supervised whilst they were waiting for their full DBS to come through but could not produce any evidence of this in relation to 2 staff whose records we reviewed. The registered manager informed us of the actions they are taking to address this. Staff received training and completion of this was monitored. Competency checks did not always take place or were not recorded.

People’s medicines were mostly managed safely. However, there was some lack of sufficient individualised and personalised information within people’s medicines records.

When providing support, staff sought people’s consent. Improvements were being made to the way issues around consent were recorded.

We received positive feedback from external health and social care professionals about how the service worked in partnership with them.

Systems and processes to assess, monitor and improve the quality and safety of the service had not been established and operated effectively. Statutory notifications had not always been sent to CQC when required. These are being submitted retrospectively.

During our visits, the registered manager was responsive to any issues we identified. Throughout the inspection, we observed some examples of effective care practices. We saw evidence of ongoing improvements being made to the premises.

We found 2 breaches of the regulations in the areas of staffing and good governance.

We have asked the provider for an action plan in response to the concerns found at this assessment.

22 January 2021

During an inspection looking at part of the service

Ashlette Dale Rest Home is a care home without nursing for up to 16 people. People using the service may have a disability, a mental health condition or they may require care and support for substance misuse.

Ashlette Dale Rest Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided.

We were assured that this service met good infection prevention and control guidelines.

• Alternative forms of maintaining social contact were used to ensure people were able to stay in touch with their friends and relatives; for example: through using video calls and visiting in communal garden or through meeting at a closed window. Technology was also used effectively to support communication with other visitors such as professionals and for clinical consultations.

• Staff wore appropriate personal protective equipment (PPE) when providing care and support.

• There were designated areas for donning/doffing PPE.

• The service ensured patients had been tested for COVID-19 by the hospital, or in the community before they agreed to admit them.

• For people who lacked mental capacity, the service had considered if any new measures and arrangements in relation to infection, prevention and control (IPC) amounted to a ‘deprivation of liberty’ and had taken appropriate action.

• The testing scheme for all staff and residents known as ‘whole home testing’ had been conducted and was on ongoing process.

• Risk assessments had been carried out on people and staff belonging to higher risk groups and actions had been taken to reduce the risk of these contracting Coronavirus.

• All care home workers had a test without delay if they became symptomatic and the frequency of testing followed current guidance.

• Communal areas such as outdoor spaces and garden areas were used creatively to help with IPC.

• All areas were uncluttered so cleaning could take place effectively.

• Employees in the clinically ‘extremely vulnerable’ group do not work in the care setting.

• All staff in high risk groups such as black and minority ethnic (BAME) groups had been risk assessed, and adjustments had been made.

• The registered manager demonstrated a good understanding of when and how to access local IPC resources (for example the local health protection team or infection control nurse) when they needed advice and support.

3 January 2018

During a routine inspection

We carried out an unannounced inspection of this home on 3 January 2018. The home is registered to provide accommodation and personal care for up to 16 older people, some of whom live with dementia. Accommodation is arranged over two floors with access to all areas by stairs and a stair lift. At the time of our inspection 16 people lived at the home.

The registered provider of this service was an individual, Mrs Collette Willis. They were not required to appoint a manager as a condition of their registration. This individual was the registered person with legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run. This was the first inspection of this care home under this registered provider.

Risk assessments were in place to support staff in identifying and mitigating the risks associated with people’s care; however some risks which had been identified were not clearly recorded.

Staff knew how to keep people safe and understood how to report any concerns they may have about the care people received.

There were sufficient staff deployed to meet people’s needs and ensure their safety and welfare. Staff recruited to the home had been assessed as to their suitability to work with people.

Where people could not consent to their care, staff sought appropriate guidance and followed legislation designed to protect people’s rights and freedom.

People received nutritious food in line with their needs, likes and preferences.

People were cared for in a kind and sensitive way by staff who had a good understanding of their needs. People said staff were caring and supportive of their needs. Health and social care professionals said staff were caring.

Care plans were individualised, person centred and were mostly up to date. These were being reviewed and a new electronic system of records was being considered.

There was a system in place to allow people to express any concerns or complaints they may have, and people and staff had the opportunity to express their views on the quality and effectiveness of the service provided at the home.

The provider had an effective system of audits in the home to ensure the safety and welfare of people.

The provider promoted an open and honest culture for working which was fair and supportive to people who lived and worked in the home.